Pattern of Psychotropic

Prescribed in Bipolar Disorder

Patient in Indonesia

Andi J. Tanra

Department of Psychiatry, Faculty of Medicine,

Hasanuddin University,

Makassar, Indonesia

Seoul,PRCP,Oct.2012

Background Bipolar disorder is one of the most frequent misdiagnosed Bipolar

disorder is one of the most frequent misdiagnosed and under and

under-diagnosed psychiatric disorders diagnosed psychiatric disorders

Misdiagnosis and under Misdiagnosis and under-diagnosis lead to

mistreatment diagnosis lead to mistreatment and under and under-

treatment treatment

Worsen the prognosis Worsen the prognosis

Various clinical appearances, made the diagnosis become Various

clinical appearances, made the diagnosis become more difficult and

therapist mostly use the combination more difficult and therapist mostly

use the combination therapy (standard of care)* therapy (standard of

care)*

Trying to find out solution of several problems, especially Trying to

find out solution of several problems, especially the epidemiological data

of BPD in Surabaya the epidemiological data of BPD in Surabaya-

Indonesia Indonesia

•Keck PE Jr, et al. Am J Psych 1998;155(5):646-65

•By Andi J. Tanra, 2012

Serious Consequences of Misdiagnosis

of Bipolar Disorder

• Incorrect treatment can worsen Incorrect treatment can worsen symptoms and prognosis

symptoms and prognosis

• Increased risk of suicide Increased risk of

suicide

• Increased cost of treatment Increased cost of

treatment

• Resources wasted Resources wasted

• Lowering patient quality of life Lowering

patient quality

By Andi J. Tanra, 2012

Method

• We collecting patients from medical record

in Several Hospitals in Makassar.

• We made cathegorize of

Demography,Diagnostic type of BD,

pattern of prescribed and we compare to

developed countries,

• All variable will be compared to other

Developed countries.

CHARATERISTIC OF BIPOLAR

DISTRIBUTION IN MAKASSAR INDONESIA

By Andi J Tanra, 2012

LIST DIAGNOSTIC CODE BY ICD X

DIAGNOSIS CODE :

• F31.0 AFFECTIVE BIPOLAR DISORDER (ABD) MOST RECENT (–) HYPOMANIC EPISODE (EP.)

• F31.1 ABD – MANIC EP. WITHOUT PSYCHOTIC SYMPTOMS (SYMP.)

• F31.2 ABD – MANIC EP. WITH PSYCHOTIC SYMP.

• F31.3 ABD – MINOR DEPRESSION EP.

• F31.4 ABD – MAJOR DEPRESSION EP. WITHOUT PSYCHOTIC SYMP.

• F31.5 ABD – MAJOR DEPRESSION EP. WITH PSYCHOTIC SYMP.

• F31.6 ABD – MIXED EP.

• F31.7 ABD – IN REMISSION

• F31.8 ABD – OTHER EP.

• F31.9 ABD – UNSPECIFIED EP.

By Andi J. Tanra 2012

3

39

4

14

26

1 2

0

10

20

30

40

50

F31.1 F31.2 F31.3 F31.4 F31.5 F31.6 F31.7

BIPOLAR DISTRIBUTION DIAGNOSIS IN

MAKASSAR INDONESIA

By Andi j. Tanra, 2012

MONOTHERAPY AND MIXED THERAPY

OF BIPOLAR DISORDER IN MAKASSAR

By Andi j. Tanra,2012

NUMBER DISTRIBUTION OF BIPOLAR

DISORDER IN MAKASSAR

By Andi j. Tanra,2012

5,7

30,3

10,1213,5

24,7

6,73,37 2,24 3,37

05

101520253035

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MEAN DOSE TREATMENT OF BIPOLAR IN

MAKASSAR

By Andi j. Tanra, 2012

DISTRIBUTION OF POSSIBLE BIPOLAR

IN MAKASSAR

By Andi j. Tanra, 2012

88

111

43

106

50

89

19

65

9

17

1

23

4 6

1

31

133

0

20

40

60

80

100

120

140

MALE

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LD

35 - 5

1 YEA

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52 - 6

9 YEA

RS O

LD

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SE

MACA

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F31.1

F31.2

F31.3

F31.4

F31.9

F32.2

F32.3

SEX AGE TRIBE CODE OF DIAGNOSIS

DISTRIBUTION OF POSSIBLE BIPOLAR

IN MAKASSAR

By Andi j. Tanra,2012

Prevalence of Possible Bipolar Disorder among various population group in Surabaya-Indonesia

Maramis MM et al. 2010

Using MDQ

No. Items Government OPU Private practice

Prevalence BD 1.3 % 2.7 %

1 Mood stabilizer 58.2 % 69.4 %

2 Antipsychotics 70.2 % 63.5 %

3 Antidepressant 43.3 % 45.9 %

4 Mood stabilizer only 11.9 % 12.9 %

5 Antipsychotics only 14.9 % 10.6 %

6 Antidepressant only 10.5 % 5.9 %

7 Monotherapy 37.3 % 29.4 %

8 MS and AP 29.8 % 30.6 %

9 MS and AD 7.5 % 17.7 %

10 AP and AD 16.4 % 14.1 %

11 MS + AP + AD 9.0 % 8.2 %

12 Combo therapy 62.7 % 70.6 %Maramis MM, 2011. Pattern of psychopharmacotherapy in BD between private practice and government hospital outpatient clinic.

Proportion of time in treatment with antipsychotic medication

Prescribing of the 5 most common antipsychotic medication by sex.

A) Male, B) Female

Proportion of time in treatment with mood stabilizer medication

Prescribing of mood stabilizer by sex. A) Male, B) Female

Percentage of treated individuals by medication group in A) 1995,

and B) 2009

Overall summary of efficacy of

pharmaceutical interventionsDrugs which have

statistically significant

benefit compared with

placebo

Drugs which have

statistically

significant benefit

compared with

lithium

To prevent all relapses

To prevent depressive relapses

To prevent manic relapses

Lithium

Valproate

Lamotrigine

Olanzapinea

Valproate

Lamotrigine

Imipramine

Lithium

Olanzapinea

Olanzapine

Olanzapine

a Based on the results of a trial that only included participants who had already

responded to olanzapine.Soares-Weiser et al., Health Technol Assess 2007 Oct;11(39):iii-iv, ix-206.

Mean Dose of Lithium and Valproate by Age

Al Jurdi et al., Am J Geriatr Psychiatry. 2008 November ; 16(11): 922–933

Discussion and conclusion• Incidence of BD , female more high than male.

• High frequency in age 35- 51

• Manic with psychotic symptoms, major

depression with psychotic symptoms and major

depression without psychotic symptoms.

• MS+TA 30,3%, TA+AD 24,7%, MS+AD 13,5%,

MS+AA 10,12%.

• We need to collect more much of number of

patients for accurate data.

• As severe symptoms BD we found, we need

more number of mood stabilizer and atypical

antipsychotic for better out come.

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2009

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neuroimaging findings in bipolar disorder: an updated review. Bipolar Disord 2012: 14: 375–410.

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• Joseph Hayes1*, Philip Prah2, Irwin Nazareth2,3, Michael King1, Kate Walters3, Irene Petersen3,

David Osborn1 1 Mental Health Sciences Unit, University College London, London, United

Kingdom, 2 MRC General Practice Research Framework, London, United Kingdom, 3 Department

of Primary Care and Population Health, University College London, London, United Kingdom

• Rayan K. Al Jurdi1, Lauren B. Marangell1, Nancy J. Petersen, PhD2, Melissa Martinez1, Laszlo

Gyulai3, and Martha Sajatovic4 Am J Geriatr Psychiatry. 2008 November ; 16(11): 922–933. Gin

S Malhi1,2, Michelle Tanious1,2, Pritha Das1,2 and Michael Berk Australian & New Zealand

Journal of Psychiatry 46(3) 192–211 The Royal Australian and New Zealand College of

Psychiatrists 2012